anorexia nervosa

Anorexia nervosa

Definition

Anorexia nervosa is a psychiatric disorder characterized by an unrealistic fear of weight gain, self-starvation, and conspicuous distortion of body image. The individual is obsessed with becoming increasingly thinner and limits food intake to the point where health is compromised. The disorder may be fatal. The name comes from two Latin words that mean nervous inability to eat.

Description

Anorexia nervosa often is thought of as a modern problem, but it was first described by the English physician Richard Morton in 1689. Nevertheless, anorexia was not officially classified as a psychiatric disorder by the American Psychiatric Association until the third edition of the Diagnostic and Statistical Manual of Mental Disorders published in 1980. In the twenty-first century, anorexia nervosa is recognized as a serious problem particularly among adolescent females. Its incidence in the United States has more than doubled since 1970. The rise in the number of reported cases is thought to reflect a genuine increase in the number of persons affected by the disorder and not simply earlier or more accurate diagnosis.Anorexia nervosa is a serious public health problem not only because of its rising incidence, but also because it has one of the highest mortality rates of any psychiatric disorder. Individuals with anorexia are irrational and unrelenting in their quest to lose weight. No matter how much weight they lose and how much their health is compromised, they want to lose more weight. Anorexia may cause serious long-term health complications, including congestive heart failure, sudden death, growth retardation, dental problems, constipation, stomach rupture, swelling of the salivary glands, anemia and other abnormalities of the blood, loss of kidney function, electrolyte imbalances, and osteoporosis.There are two major subtypes of anorectics. Restrictive anorectics control their weight by rigorously limiting the amount of calories they eat or by fasting. They may exercise excessively or abuse drugs or herbal remedies claim to increase the rate at which the body burns calories. Purge-type anorectics eat and then get rid of the calories and weight by self-induced vomiting, excessive laxative use, and abuse of diuretics or enemas.About 95% of anorectics are female. It is estimated that one out of every 100-200 adolescent females meet all the Diagnostic and Statistical Manual for Mental Disorders Fourth Edition (DSM-IV-TR) criteria for anorexia. However, it has been suggested that as many as 5% of adolescent females show some characteristics of the disorder but do not meet the full diagnostic criteria. The rate among men is about 0.1%.About 85% of anorectics develop the disorder between ages 13 and 18; there is a secondary peak of individuals who become anorexic in their 40s. Originally anorexia was thought to be primarily a disorder of white, upper-middle class girls, but now it is known to be found among all races and socioeconomic groups. The disorder, however, is not evenly distributed among pastimes or occupations. Women involved in gymnastics, figure skating, dance (especially ballet), cheerleading, acting, and modeling have a much higher rate of anorexia than the general population. Men involved in wrestling, gymnastics, cross-country running, and modeling have higher than average rates. The disorder is more often diagnosed in homosexual men than in heterosexuals.

Causes and symptoms

Anorexia is a disorder that results from the interaction of cultural and biological factors. Research suggests that some people have a predisposition toward anorexic and that something triggers the behavior, which then becomes self-reinforcing. Hereditary, biological, psychological and social factors all appear to play a role.While the precise cause of the disorder is not known, it has been linked to the following:

Heredity. Twin studies show that if one twin has anorexia nervosa, the other has a greater likelihood of developing the disorder. Having a close relative, usually a mother or a sister, with anorexia nervosa also increases the likelihood of other (usually female) family members developing the disorder. However, when compared to many other diseases, the inherited component of anorexia nervosa appears to be fairly small.

Biological factors. There is some evidence that anorexia nervosa is linked to abnormal neurotransmitter activity in the part of the brain that controls pleasure and appetite. Neurotransmitters are also involved in other mental disorders such as depression. Research in this area is relatively new and the findings are unclear. People with anorexia tend to feel full sooner than other people. Some researchers believe that this is related to the fact that stomach of people with anorexia tends to empty more slowly than normal; others think it may be related to the appetite control mechanism of the brain.

Psychological factors. Certain personality types appear to be more vulnerable to developing anorexia nervosa. Anorectics tend to be perfectionists who have unrealistic expectations about how they "should" look and perform. They tend to have a black-or-white, right-or-wrong, all-or-nothing way of seeing situations. Many anorectics lack a strong sense of identity and instead take their identity from pleasing others. Virtually all anorectics have low-self worth. Many experience depression and anxiety disorders, although researchers do not know if this is a cause or a result of the eating disorder.

Social factors. Anorectics are more likely to come either from overprotective families or disordered families where there is a lot of conflict and inconsistency. Either way, the anorectic feels a need to be in control of something, and that something becomes body weight. The family often has high, sometimes unrealistic, and rigid expectations. Often something stressful or upsetting triggers the start of anorexic behaviors. This may be as simple as a family member as teasing about the person's weight, nagging about eating junk food, commenting on how clothes fit, or comparing the person unfavorably to someone who is thin. Life events such as moving, starting a new school, breaking up with a boyfriend, or even entering puberty and feeling awkward about one's changing body can trigger anorexic behavior. Overlaying the family situation is the unrelenting media message that thin is good and fat is bad; thin people are successful, glamorous, and happy, fat people are stupid, lazy, and failures.

Male anorectics

Although anorexia nervosa is still considered a disorder that largely affects women, its incidence in the male population is rising. Less is known about the causes of anorexia in males, but some risk factors are the same as for females. These include certain occupational goals (e.g., jockey) and increasing media emphasis on external appearance in men. Moreover, homosexual males are under pressure to conform to an ideal body weight that is about 20 pounds lighter than the standard "attractive" weight for heterosexual males.

Symptoms

Recognizing the development of anorexia can be difficult, especially in a society that values and glamorizes thinness. Dieting often is the trigger that starts a person down the road to anorexia. The future anorectic may begin by skipping meals or taking only tiny portions. She (most anorectics are female) always has an excuse for why she does not want to eat, whether it is not feeling hungry, feeling ill, having just eaten with someone else, or not liking the food served. She also begins to read food labels and knows exactly how many calories and how much fat are in everything she eats. Many anorectics practically eliminate fat and sugar from their diets and seem to live on diet soda and lettuce. Some future anorectics begin to exercise compulsively to burn extra calories. Eventually these practices have serious health consequences. At some point, the line between problem eating and an eating disorder is crossed.Anorectics spend a lot of time looking in the mirror, obsessing about clothing size, and practicing negative self-talk about their bodies. Some are secretive about eating and will avoid eating in front of other people. They may develop strange eating habits such as chewing their food and then spitting it out, or they may have rigid ideas about "good" and "bad" food. Anorectics will lie about their eating habits and their weight to friends, family, and health care providers. Many anorectics experience depression and anxiety disorders.

Diagnosis

Diagnosis of anorexia nervosa is complicated by a number of factors. One is that the disorder varies somewhat in severity from patient to patient. A second factor is that most anorectics deny that they are ill. Eventually they usually are brought to treatment by a family member. Most anorectics are diagnosed by pediatricians or family practitioners.Anorexia nervosa is diagnosed when most of the following conditions are present:

an overriding obsession with food and thinness that controls activities and eating patterns every hour of every day

the individual weighs less than 85% of the average weight for his or her age and height group and willfully and intentionally refuses to maintain an appropriate body weight

extreme fear of gaining weight or becoming fat, even when the individual is significantly underweight.

a distorted self-image that fuels a refusal to admit to being underweight, even when this is demonstrably true

refusal to admit that being severely underweight is dangerous to health

for women, three missed menstrual periods in a row after menstruation has been established

In addition to weight loss, anorectics develop emaciated bodies, dry or yellowish skin, and abnormally low blood pressure. There is usually a history of amenorrhea in females, and sometimes of abdominal pain, constipation, or lack of energy. The patient may feel chilly or have developed lanugo, an abnormal growth of downy body hair that is a sign of starvation. If the patient has been vomiting, she may have eroded tooth enamel or Russell's sign (scars on the back of the hand).lossThe doctor will need to do tests to rule out other physical conditions that can cause weight loss or vomiting after eating, including metabolic disorders, brain tumors (especially hypothalamus and pituitary gland lesions), diseases of the digestive tract, and a condition called superior mesenteric artery syndrome. Persons with this condition sometimes vomit after meals because the blood supply to the intestine is blocked. The doctor usually will order blood tests, an electrocardiogram, urinalysis, and bone densitometry (bone density test) in order to exclude other diseases and to assess the patient's nutritional status.The doctor also will need to distinguish between anorexia and other psychiatric disorders, including depression, schizophrenia, social phobia, obsessive-compulsive disorder, and body dysmorphic disorder. Two diagnostic tests that are often used are the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI).

Treatment

Treatment of anorexia nervosa includes both short- and long-term measures, and requires assessment by dietitians and psychiatrists as well as medical specialists. Therapy is often complicated by the patient's resistance or failure to carry out a treatment plan.

Hospital treatment

Hospitalization is recommended for anorexics with any of the following characteristics:

weight of 40% or more below normal; or weight loss over a three-month period of more than 30 pounds

severely disturbed metabolism

severe binging and purging

signs of psychosis

severe depression or risk of suicide

family in crisis

Hospital impatient care is first geared toward correcting problems that present as immediate medical crises, such as severe malnutrition, severe electrolyte imbalance, irregular heart beat, pulse below 45 beats per minute, or low body temperature. In extreme cases, hospitalized patients may be force-fed through a tube inserted in the nose (nasogastric tube) or by over-feeding (hyperalimentation techniques). There is often a high level of resistance to treatment. After the individual is physically stable, treatment includes individual and group therapy as well as re-feeding and monitoring of the patient's physical condition. Treatment usually requires two to four months in the hospital.

Outpatient treatment

Anorectics who are not severely malnourished may be treated by outpatient psychotherapy and nutritional counseling. The types of treatment recommended are supportive rather than insight-oriented, and include behavioral approaches as well as individual and/or group therapy. Family therapy is often recommended when the patient's eating disorder is closely tied to family dysfunction. Self-help groups often are useful in helping anorectics find social support and encouragement. Psychotherapy with anorectics is a slow and difficult process; about 50% of patients continue to have serious psychiatric problems after their weight has stabilized.

Medications

Anorectics are treated with a variety of medications to address physical problems brought about by their eating disorder and to treat additional psychiatric problems such as depression, anxiety, and suicidal thoughts. The medications used will vary depending on the individual, however, depression is common among anorectics and is treated often treated with antidepressant drugs.

Prognosis

Only about half of all anorectics will make a good, long-term physical and social recovery. The mortality rate is estimated at 6-20%. The most frequent causes of death associated with anorexia are starvation, electrolyte imbalance, heart failure, and suicide. Other long-term health complications are common.

Prevention

Short of major long-term changes in the larger society, the best strategy for prevention of anorexia is the cultivation of healthy attitudes toward food, weight control, and beauty (or body image) within familiesSome specific ways to reduce the likelihood that anorexia nervosa will develop follows:

If you are a parent, do not obsess about your own weight and appearance in front of your children.

Do not tease your children about their body shapes or compare them to others.

Make it clear that you love and accept your children as they are.

Try to eat meals together as a family whenever possible.

Remind children that the models they see on television and in fashion magazines have extreme, not normal or healthy bodies.

Do not put your child on a diet unless advised to by your pediatrician.

Block your child from visiting pro-anorexia Web sites. These are sites where people with anorexia give advice on extreme weight loss techniques and support each other's distorted body image.

If your child is a competitive athlete, get to know the coach and the coach's attitude toward weight.

If you think your child has an eating disorder, do not wait to intervene and the professional help. The sooner the disorder is treated, the easier it is to cure.

Key Terms

Amenorrhea

Absence of the menses in a female who has begun to have menstrual periods.

Body dysmorphic disorder

A psychiatric disorder marked by preoccupation with an imagined physical defect.

A method of re-feeding anorectics by infusing liquid nutrients and electrolytes directly into central veins through a catheter.

Lanugo

A soft, downy body hair that develops on the chest and arms of anorexic women.

Neurotransmitter

One of a group of chemicals secreted by a nerve cell (neuron) to carry a chemical message to another nerve cell, often as a way of transmitting a nerve impulse. Examples of neurotransmitters include acetylcholine, dopamine, serotonin, and norepinephrine.

Purging

The use of vomiting, diuretics, or laxatives to clear the stomach and intestines after a binge.

Russell's sign

Scraped or raw areas on the patient's knuckles, caused by self-induced vomiting.

Superior mesenteric artery syndrome

A condition in which a person vomits after meals due to blockage of the blood supply to the intestine.

anorexia

[an″o-rek´se-ah]

lack or loss of appetite; appetite is psychological, dependent on memory and associations, as compared with hunger, which is physiologically aroused by the body's need for food. Anorexia can be brought about by subjectively unpleasant food, surroundings, or company, or emotional states such as anxiety, irritation, anger, or fear; it may also be a symptom of a physical disorder or emotional disturbance.

anorexia nervo´sa an eating disorder consisting of loss of appetite due to emotional states, such as anxiety, irritation, anger, and fear. In true anorexia nervosa there is no real loss of appetite, but rather a refusal to eat or an aberration in eating patterns; hence, the term anorexia is probably a misnomer. The clinical picture is usually that of a young woman who is obsessed with the idea of being thin and restricts her food intake to the point of danger; she may alternate fasting with periods of bingeing (bulimia). She often may be described as “a model child” with perfectionistic tendencies. A personal crisis often triggers the disorder.

The syndrome was first described more than 300 years ago and was once thought to be exceedingly rare. However, in recent years its incidence has been rapidly increasing throughout the world in developed countries as diverse as Russia, Japan, Australia, and the United States. The condition occurs mainly in girls after the age of puberty, and the prevalence may be as high as one in a hundred.

Cause. The cause of anorexia nervosa is unknown, but it is thought to be a complex of psychological, social, and biological factors. There are numerous theories, such as that the victim is attempting to control some aspects of life in an environment where it is difficult to exert control; that it is an attempt to manipulate others and gain attention; and social pressures, conflicting roles, and family disorders that serve as stimuli. Other theorists hypothesize that the disorder is a defense against sexual maturation, related to a fear of sexual intimacy. Society's obsession with physical appearance is also thought by some to play a role. Researchers are studying whether there could be a genetic component, as well as whether malfunction of the hypothalamus might play a role.

Symptoms. Criteria for diagnosis of anorexia nervosa identified by the American Psychiatric Association are as follows: (1) intense fear of becoming obese that does not diminish as weight loss progresses; (2) disturbance of body image, such as claiming to feel fat even when emaciated; (3) refusal to maintain body weight over a minimal normal weight for age and height; (4) no known physical illness that would account for the weight loss; and (5) amenorrhea in postmenarchal females. It is often accompanied by self-induced vomiting or use of laxatives and/or diuretics (see also bulimia nervosa) and extensive exercise. Accompanying physical signs in addition to profound weight loss include hypotension, bradycardia, edema, lanugo, metabolic changes, and endocrine disturbances.

Treatment. The treatment of anorexia nervosa is difficult and lengthy. The primary goals are restitution of normal nutrition and resolution of underlying psychological problems. Modes of therapy that can be used include behavior therapy, behavioral contracts, psychoanalysis, group therapy, insight-oriented therapy, and family therapy.

Nutritional counseling, social services and support, health education, and health care are all components in the physical and psychological recovery from an eating disorder. The physical sequelae, as well as the social and cultural aspects, require a multidisciplinary approach individualized to the unique needs of the victim and family. Inpatient treatment, either partial or complete, is required when the individual's problems warrant intensive services or if outpatient treatment is not successful. Some hospitals have special units for patients with eating disorders, providing an environment for treatment that emphasizes the simultaneous treatment of physiologic and psychological problems by professionals trained in the management of these patients. The American Psychological Association has identified numerous areas for research related to eating disorders.

Information and support for professionals as well as persons affected by the disorder can be obtained from the National Association of Anorexia Nervosa and Associated Disorders by writing to them at P.O. Box 7, Highland Park IL 60035 or calling their hotline at 1-847-831-3438.

an·o·rex·i·a ner·vo·sa

a mental disorder manifested by extreme fear of becoming obese and an aversion to food, usually occurring in young women and often resulting in life-threatening weight loss, accompanied by a disturbance in body image, hyperactivity, and amenorrhea.

Anorexia nervosa (AN) has been defined as a compulsive pursuit of thinness at the expense of health. It is characterized by steady weight loss, to and below 85% of normal weight for height, achieved by rigorous dieting, often supplemented by strenuous exercise and sometimes by self-induced vomiting or the use of diuretics or laxatives. Onset is typically during adolescence; 90% of patients are women. Estimates of prevalence range from 0.3-3% of girls and women between the ages of 10 and 25. Risk factors include white race, upper-class background, and a compulsive, perfectionistic personality. Body image is grossly distorted, with perception of a normal habitus, and even an emaciated one, as obese. Despite limited insight, patients are often highly manipulative, denying their dietary practices, shunning encounters with health care professionals, and choosing clothing that conceals their thinness. Physical consequences of AN, in addition to wasting of muscle and loss of subcutaneous fat, include anemia, electrolyte imbalance, bradycardia, hypotension, asthenia, exaggerated sensitivity to cold, constipation, and dryness and scaliness of skin with increased pigmentation and growth of lanugo. Women become amenorrheic and are at risk of osteoporosis and stress fractures or irreversible bone deformation, The female athletic triad (disordered eating, amenorrhea, and osteoporosis) is associated particularly with sports that emphasize low body weight, such as running, swimming, gymnastics, and figure skating. Cognitive-behavioral therapy and treatment with antidepressants, lithium, or other agents lead to remission in many patients, but the relapse rate is high. Severe cachexia or extreme dietary deviance may require hospitalization and intravenous correction of acute nutritional and electrolyte deficiencies. At least 50% of patients have persistent psychiatric problems throughout life, particularly with eating and sexuality. The mortality rate of AN is about 5%.

anorexia nervosa

(nûr-vō′sə)

n.

An eating disorder that is characterized by an intense fear of gaining weight, a distorted self-image, a persistent unwillingness to eat, and extremely low body weight, and is often accompanied by self-induced vomiting or excessive exercise. It most commonly affects young women and can lead to amenorrhea, malnutrition, brittle bones, and other physiological changes.

anorexia nervosa

a disorder characterized by a prolonged refusal to eat, resulting in emaciation, amenorrhea, emotional disturbance concerning body image, and fear of becoming obese. The condition is seen primarily in adolescents, predominantly in girls, and is usually associated with emotional stress or conflict, such as anxiety, irritation, anger, and fear, which may accompany a major change in the person's life. Treatment consists of measures to improve nourishment, followed by therapy to overcome the underlying emotional conflicts.

an·o·rex·ia ner·vo·sa

(an'ŏ-rek'sē-ă nĕr-vō'să)

A personality disorder manifested by extreme fear of becoming obese and an aversion to eating, usually occurring in young women and often resulting in life-threatening weight loss, accompanied by a disturbance in body image, hyperactivity, and amenorrhea.

anorexia nervosa

A serious disorder of perception causing the sufferer, almost always a young woman, to believe that she is too fat, when, in fact, she may be very thin. Food intake is drastically reduced and emaciation results. Treatment is difficult and the best efforts of those trying to help are often frustrated by the determination of the sufferer to avoid eating. Hospital treatment is usually necessary as there is a real risk of a fatal outcome, often from suicide.

anorexia nervosa

personality disorder characterized by extreme food aversion more commonly affecting young women, characterized by extreme weight loss, amenorrhoea and even death

an·o·rex·ia ner·vo·sa

(an'ŏ-rek'sē-ă nĕr-vō'să)

Mental disorder manifested by extreme fear of becoming obese and an aversion to food, usually occurring in young women and often resulting in life-threatening weight loss, accompanied by a disturbance in body image, hyperactivity, and amenorrhea. Compare: bulimia nervosa

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